Adding a Refused Immunisation

To record an immunisation refusal:

1. From Consultation Manager , select the patient required and start a consultation if required.
2. Select Add - Immunisations, remember you can use <Alt+A> then <Alt+I> if using the keyboard.
3. The Immunisation - Add screen displays:

   

   Complete as follows:

   • Date Given - Defaults to today's date, update to the date of the refusal.
   • Given by - Defaults to the staff member or GP signed on for the current session, update as required.
   • Private - Defaults to unticked, tick if you are recording a private immunisation.
   • READ Term for Immunisation - Disabled until Type of Immunisation is selected, it is then updated with the Read code and description relevant to the immunisation selected.
   • Show All - Default unticked, so only current immunisations are displayed in Type of Immunisation. Tick to display all immunisation options, including historical options in the Type of Immunisation list.
   • Type of Immunisation - Select the immunisation being refused from the list of immunisations, see Type of Immunisation for details.
     Note - If you cannot find the immunisation type you want, use either Other Single vaccination or Other Combined vaccination.
   • Stage - Depending on the immunisation, select from the available list as required, for example 1st, 2nd or Booster.
   • Status - Select Refusal to start or complete course.

   • Review Date - Automatically entered based on the Type of Immunisation and Stage selected, update as required.

   • Method - Inactivated.
   • In Practice - Defaults to In this Practice, select from the available list as required.
   • Reason - Inactivated
   • Nature of Risk/Country - Inactivated.
   • Batch Number - Leave blank.
   • Site - Defaults to <None>.
   • Notes - Select to enter free text comments if required.
4. Select OK to save and close.

Refused immunisations display as Refused Immunisation alongside the record. As Vision 3 splits combined vaccinations their refusal is marked by multiple entries, for example, an MMR refusal adds three separate Refusal to start or complete course entries to the patient record. This means you can search for measles, mumps or rubella with the positive immunisation code, and then specify the Refused status in the search.

 

You can also record a Medical History entry with a suitable Read code, for example:

• 9OX5100 Seasonal Influenza vaccination declined